Healthcare: Dubious Distinctions

By Samia Altaf

Two recent reports about Pakistan’s health system tell of deficiencies of far reaching significance.

The first, from UNICEF, confers on Pakistan the dubious distinction of registering the highest number of deaths in newborns (neonatal mortality) in the past decade. It is now number one in the world, climbing from number three, and ahead of Afghanistan and the Central African Republic. The second, a National Nutrition Survey, informs that 45% of Pakistan’s children are stunted, suffering from chronic, extreme, and irreversible malnourishment that causes permanent physical and cognitive deficiencies. What would this half of future generations be capable of with its severely limited capacity to learn even if the opportunity for education is available? It would fall sick much quicker and get better a lot slower creating a permanent burden on the already constrained health service delivery system.

The situation in other areas of healthcare, though not part of these reports, is equally grim. Measles continues to be endemic with 6,494 cases last year in Pakistan compared to 1,511 in poor Afghanistan and 513 in war-torn Syria. This is a stinging indictment of the national Expanded Program on Immunization, underway since 1988, which provides 50% coverage when 90% is minimum needed for herd immunity. Maternal mortality, deaths in women due to pregnancy related events, continues to be unacceptably high — 286 per 100,000 nationally and 786 in Balochistan. Deficiencies in large city hospitals with patients dying in hospital corridors or refused treatment have forced the CJP to step in the mess that should be cleaned by the Ministry of Health. The story of spurious drugs and the problems of DRAP are too familiar to need recounting.

Isn’t it remarkable that the marked decline in health outcomes has been accompanied by a sharp increase in the number of medical colleges and universities, hospitals, doctors, nurses, and midwives. Advances in technology and fancy apps have facilitated diagnosis and treatment. Donors continue their generous funding — Punjab has received a $65 million grant from DFID and the loan of an equal amount from the World Bank. This has led to the current reform of the ministry of health — two ministers instead of one and two secretaries instead of one.

What is going on? Is it that we still don’t have enough doctors for our population? It is true that the doctor to patient ratio is half that recommended by the WHO. But then, why are so many young doctors unemployed? Why are so many people going to non-doctors? China’s population is five times that of Pakistan. Its Infant Mortality Rate (deaths in children under one year) is 12, seven times less than Pakistan’s and its Maternal Mortality Rate is 27, ten times lower. Yet, China has never tried to get its doctor to patient ratio up to the number recommended by the WHO.

“The state needs to take charge,” exhorts an editorial in this newspaper (28.2.2018). But the state is firmly in charge. New programs are launched every few months and plans to control communicable diseases in children and provide services to women are articulated in documents PC-1s. Frenzied activity is manifested in fancy new programs such as the health card scheme, the formation of public companies to manage hospital waste, the engagement of expensive foreign consultants, all amidst regular pronouncements from government officials. The state has a panel of technical experts — eminent doctors working in its system — that has been advising governments for the past many decades and continues to do so now. The results speak for themselves. Why would future results be any different if the same experts continue as advisors?

There are two sets of problems. First, there is no mechanism to critically evaluate the recommendations of the experts to determine if they are in the interest of citizens or in the self interests of the experts. No oversight is provided either by citizens or by their representatives who either do not know how to monitor or don’t sufficiently care about the situation. Ironically, suo moto notices by the Court call on the same set of experts to provide answers to the problems they should be held accountable for.

Second, the Ministry of Health lurches from one leaking hole-in-the-dyke to another driven by donor is offering funding, bright ideas of dignitaries, or explanations called forth by the judiciary. There is no overarching systemic vision compatible with the country’s constraints and challenges, none that has stood the test of time, regime-change, or public scrutiny. The mindset that survives is that more is better – more consultants, more doctors, more beds, more ministries. The results are staring us in the face as documented in the reports mentioned above.

Solutions at the margins in the absence of a robust public health system will not resolve the healthcare crisis. Just as more flyovers and underpasses cannot stay ahead of traffic congestion if the city continues to sprawl, increasing the number of doctors or hospitals cannot make up for the growing burden of disease in an unhealthy environment. Take air pollution as an example, where, on average, the exposure of Pakistanis to critical particulates is 6.5 times the safe level recommended by WHO. Asides from adding to morbidity, air pollution killed about 60,000 Pakistanis in 2012 making the country the fifth-deadliest in that category. Here too, we could be vying for first place with the commissioning of numerous coal-based power plants across the country.

The task is by no means impossible and much can be achieved with a simple focus on the provision of clean air, clean drinking water, safe sanitation, a critical education, and gender equality. In 2012, the Infant Mortality Rate in Bangladesh was less than half that of Pakistan’s although the rates were comparable in 1990. This remarkable progress in Bangladesh has occurred despite the fact that it is only two-thirds as affluent as Pakistan in terms of per capita income.

The Pakistani story has been one of neglecting the basics and channeling funds to intermediaries on half-baked schemes that yield no benefit to citizens. The global rankings provide evidence that is impossible to refute.

The writer is a public health physician and author of So Much Aid, So Little Development:Stories from Pakistan. This opinion appeared in Dawn on March 19, 2018 and is reproduced here with permission of the author.